Expediting the early hospital care of the adult patient with nontraumatic chest pain: impact of a modified ED triage protocol.

A prospective study that compared a traditional emergency department (ED) triage protocol with an expedited protocol was conducted to determine if minimizing the subjectivity of nursing triage would result in more efficient management of adult patients presenting with nontraumatic chest pain. The traditional protocol triaged 382 patients into 1 of 5 categories of acuity. The expedited study group (418 patients) were triaged as usual but subsequently were treated as if they were triage category 1 or 2 (medical evaluation within 15 minutes of arrival). Traditional triage led to 40% of acute myocardial infarction (AMI) patients being triaged into inappropriately low-acuity categories. The expedited protocol resulted in significant improvement in the following intervals: ED arrival to triage, triage to cubicle, ED arrival to cubicle, ED arrival to electrocardiogram (ECG) ordered, ED arrival to ECG available, ED arrival to physician evaluation, and ED arrival to decision to thrombolyse. Study patients with non-AMI cardiac chest pain and AMI cardiac chest pain were evaluated by a physician an average of 12 minutes and 8 minutes after ED arrival, respectively. Delays in interdepartmental processes, such as ECG-technician responsiveness, thrombolysis protocol fulfillment and thrombolytic agent delivery, negated benefits derived from improvements in internal processes. Effective coordination of the numerous processes involved in the initial ED management of adult patients with nontraumatic chest pain is required to make thrombolytic therapy for AMI within 30 minutes of patient arrival a routinely achievable goal.

Waldenström's macroglobulinemia: long-term results with the M-2 protocol.

Thirty-three patients with symptomatic Waldenström's macroglobulinemia have been treated with the M-2 protocol (BCNU, cyclophosphamide, vincristine, melphalan, and prednisone). Therapy was administered every 5 weeks for 2 years and every 10 weeks for an additional 1-3 years. Median clinical and laboratory parameters included age 70 years (range 52-87), performance status 1 (1-3), prior therapy 7, weight loss 12, symptomatic hyperviscosity 13, splenomegaly 22, lymphadenopathy 7, hemoglobin 9.6 g/dl (6.7-14.6), IgM paraprotein level 2000 mg% (340-11,600), and serum viscosity 2.1 (1.4-6.0). Responses were observed in 27 patients, of whom 21 were partial responses. Survival ranges from 1 to 120+ months with 58% of patients projected to be alive at 10 years. Twenty-one patients remain alive, of whom 10 are greater than or equal to 6 years from initiation of therapy with M-2. Treatment has been well tolerated with usually only mild to moderate hematologic toxicity. Median nadir white blood cells during the first cycle was 3000/mm3 (1000-5500). Peripheral neuropathy was seen in 54% secondary to vincristine. Nausea/vomiting, anemia requiring transfusions, and alopecia were each noted in approximately 25% of patients. Sepsis was observed in 2 patients. Two characteristics, age and prior therapy, were found to be of borderline statistical significance (p = 0.03) using univariate analysis but were not significant with multivariate analysis. The M-2 protocol may be able to produce prolonged survival in the majority of patients with Waldenström's macroglobulinemia. Additional trials are needed to develop recommendations for therapy as well as factors predictive for survival and suitability for treatment.

Use of trained mothers to teach interviewing skills to first-year medical students: a follow-up study.

This report describes an attempt to evaluate the effectiveness of "trained mother" interviews early in the medical school curriculum. As an adjunct to a first-year course that teaches interviewing techniques, half of the students were exposed to an interview with one of three trained mothers early in the course. This treatment interview was immediately followed by a feedback session which concentrated on the content and process of interviewing. At the end of the course, all students had an evaluative interview. Those students who had an initial interview and feedback session with a trained mother scored significantly higher on both the content and process of their interviews than the control group. This technique is an effective and efficient way to teach interviewing skills to medical students prior to entering any of their clinical clerkships. A follow-up assessment conducted one year later indicated that one interview with a trained mother is sufficient for optimal learning and that the skills learned are retained over at least that period of time.

The use of paraprofessionals to teach interviewing skills.

Two nonphysician mothers were each trained to give a consistent and authentic history of a child's common medical problem. At the beginning of a Pediatric Clerkship, one half the students were randomly assigned to interview one of the trained mothers. The interviews were videotaped and then replayed in an evaluative feedback session with each student. At the end of the clerkship these students were rated significantly higher on the process of interviewing than those students who did not have the initial evaluative feedback session.